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oPn`'t" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT LOP N: � { 600 East Main Street, Stockton, CA 95202-3029 SITE MITIGATION • �4..,d P . Tel phone. (209) 468-3454 Fax: (209) 468-3433 Web:www.s' ov.or UNIT IV /F0 0 WELL & BORING PERMIT APPLICATIONHECEIVLU FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REMEDIATTI Zl�lj 5 a5 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Applicatio Is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliant VAL Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health D AIGNMENTAL PERi`111T/SERVICES Site Location 2662 N.Wilson Way Cross Street Sanguinetti Lane City Stockton Zip 95205 APN 117-060-33 ProperOwner yFERRAIOLO,JOHN&MAXINE PO BOX 757 LODI 95241 (209)931-2700 Owner Address City Zip Phone C-57 Contractor All Well Abandonment Address 6626 Merchandise Way City Diamond Springs Lic 848359 Phone (530)644-1609 Consultant/Sub Cntr Advanced GeoEnvironmentat Address 837 Shaw Road City Stockton LIC 680227 Phone (800)511-9300 Billable Party Advanced GeoEnvironmentat Address same as above City Zip Phone GIS Coordinates:X Y V - I CONSTRUCTION WORK TO BE PERFORMED: ®NEW WELL/BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER) ®SOIL BORING IDs S138, 9, 10, 11 ®WELL IDs ASW2 3 4 5 6 7 8 9 10'VEW3 4 5 6 7 ❑OTHER IDs TYPE 8r#OF WELL/BORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS _❑MONITORING P9 HOLLOW STEM DIA.OF BOREHOLE 2-4" ❑MULTIPLE CASINGS❑MULTI-LEVEL WELL CASING DIA: ®EXTRACTION:Vapor/Water ❑HAMMER/DRIVEN CASING THICKNESS schd 40 TYPE OF CASING: ❑STEEL ®PVC ❑ OTHER _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL 25-65' TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE 4 91 SOIL BORING ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:RI Yes ❑No(MAXIMUM FREE FALL DEPTH IS 30 FT) 9 et]INJECTION(i.e.Air Sparge.Ozone)❑HAND AUGER GROUT SPECIFICATIONS Portland Type 1/11 _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 25-65' bsg ®BOLTED TRAFFIC BOX OR ❑STOVE PIPE CONDUCTOR CASING®No❑Yes:Casing Dia: Casing Depth: Boring Dia: COMMENTS:SB8-11 soil bonngs to 65'bsg;ASW2-10 air sparge wells screened from 60-65'bsg;VEV\3,4,5 shallow vapor extraction wells screened from 10-25'bsg;VEW 6&7 deep SVE wells screened from 30-50'bsg.ASW wells are 2"diameter and VEW wells are 4"diameter. NOTE: OFFSITE WELLS & BORINGS REQUIRE ACCESS AGREEMENTS OR ENCROACHMENT PERMITS �• DESTRUCTION WORK TO BE PERFORMED: DESTRUCTION METHOD:(CHECK ALL THAT APPLY) #OF WELL(S)TO BE DESTROYED ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT WELL IDS: ❑PRESSURE GROUT TO DEPTH OF FT BELOW SURFACE GROUT SPECIFICATIONS ❑EXPLOSIVES FROM TO FT BELOW SURFACE TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ❑ PIPE ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE COMMENTS 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE)FOR INSPECTION APPOINTMENTS I hereby certify that I have prepared this ap Ii ti and that the work will be done in accordance with San Joaquin County Ordinances, Rules andY Regulations,and all a plicabl alif nia I s. Signed Title/Company Project Manager/Advanced GeoEnvironmental, Inc. Print Name Ally Colavita Date DEPARTMENT USE ONLY CO SITE MAP IN UNIT IV FILE-SITE ADDRE S Zf� /�l`�• 1LOP WORK PLAN DATED APPLICATION ACCEPTED BY DATE ISED AREA GROUT INSPECTION BY FINAL INSPECTION BY DATE ell DESTRUCTION INSPECTION BY DATE COMMENTS/CONDITIONS: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# INVOICE REQUEST PR# 3`501 $122 x TFV^ED* SR# 0(0= 0 K 3� 3 00 Z C-57 of WC WAIVEI - 7 LETTER OF AUTHORIZATION TO SIGN PERK EN)WQ IW D DC EHD 29-01 07/28/10 w, p p ELL PER APP �